Psychiatric sequelae in seriously ill children and their families

Long-Term Social Outcomes of Pediatric Liver Transplant Recipients: Transition From Childhood to Adulthood

OBJECTIVES

Chronic disorders may negatively affect people's learning status, marital status, occupational life, and social life. Liver transplant is the only curative treatment for chronic liver diseases. This study was undertaken to evaluate the psychosocial effects of liver transplant in adult patients who had undergone liver transplant during the pediatric period compared with psychosocial facts in the general population.

MATERIALS AND METHODS

We retrospectively reviewed adult patients (>18 years of age) who had received liver transplant as children. We compared sex, age at the time of transplant, current age, type of donor, graft survival status, marital status, age at first delivery, number of children, educational status, and occupational status in the study population versus the general (normal) population. To compare the liver transplant patients included in the study with the general population correctly, we used data from the Turkish Statistical Institute.

RESULTS

Among 77 liver transplant patients included in our study, the mean age at transplant was 10.9 years (range, 0.5-16 y) and the mean age at the time of the study was 25.2 years (range, 18-42 y). Of the patients, 61 (79.2%) were single and 16 (20.8%) were married. Patients in the study population married at a younger age than the general population (25.5 vs 28.1 y for men, 24.3 vs 25.4 y for women). Of 16 married patients, 9 (56.2%) had a healthy child or children. The percentage of patients who graduated from higher education or were continuing their higher education process was higher in our study population than in the general population (36.3% vs 22.8%). Among our study population, 37 patients (48%) were workers.

CONCLUSIONS

Liver transplant had no negative effects on the social, educational, and professional lives among adults in our study who received transplants in the pediatric period.

Education support services for improving school engagement and academic performance of children and adolescents with a chronic health condition

BACKGROUND

Chronic health conditions in children and adolescents can have profound impacts on education, well-being and health. They are described as non-communicable illnesses that are prolonged in duration, do not resolve spontaneously, and rarely cured completely. Due to variations in the definition of chronic health conditions and how they are measured prevalence estimates vary considerably and have been reported to be as high as 44% in children and adolescents. Of young people with a chronic health condition, an estimated 5% are affected by severe conditions characterised by limitations to daily activities impacting their ability to attend school. School attendance is important for academic and social skill development as well as well-being. When children and adolescents are absent from school due to a chronic health condition, school engagement can be affected. Disengagement from school is associated with poorer academic achievement, social-emotional functioning and career choices. Education support services for children and adolescents with chronic health conditions aim to prevent disengagement from school, education and learning during periods where their illness caused them to miss school. However, there is limited evidence on the effectiveness of educational support interventions at improving school engagement and educational/learning outcomes for children and adolescents with chronic health conditions.

OBJECTIVES

To describe the nature of educational support interventions for children and adolescents with a chronic health condition, and to examine the effectiveness of these interventions on school engagement and academic achievement.

SEARCH METHODS

We searched eight electronic databases which span the health/medical, social sciences and education disciplines between 18 and 25 January 2021: Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (Ovid), Embase (Ovid). CINAHL (EBSCO), PsycINFO (EBSCO), ERIC (Education Resources Information Center), Applied Social Sciences Index and Abstracts: ASSIA (ProQuest), and PubMed (from 2019). We also searched five grey literature trials registers and databases between 8 and 12 February 2021 to identify additional published and unpublished studies, theses and conference abstracts, as well as snowballing reference lists of included studies.

SELECTION CRITERIA

Randomised controlled trials (RCTs), controlled before-and-after studies and interrupted time series studies that met the inclusion criteria were selected. Other inclusion criteria were: participants - must include children or adolescents (aged four to 18 years) with a chronic health condition, intervention - must include educational support, outcomes - must report the primary outcomes (i.e. school engagement or academic achievement) or secondary outcomes (i.e. quality of life, transition to school/school re-entry, mental health or adverse outcomes).

DATA COLLECTION AND ANALYSIS

Two people independently screened titles and abstracts, and full-text articles, to identify included studies. Where disagreements arose between reviewers, the two reviewers discussed the discrepancy. If resolution was unable to be achieved, the issues were discussed with a senior reviewer to resolve the matter. We extracted study characteristic data and risk of bias data from the full texts of included studies using a data extraction form before entering the information into Review Manager 5.4.1. Two people independently extracted data, assessed risk of bias of individual studies and undertook GRADE assessments of the quality of the evidence. Meta-analysis was not possible due to the small number of studies for each outcome. Our synthesis, therefore, used vote-counting based on the direction of the effect/impact of the intervention.

MAIN RESULTS

The database searches identified 14,202 titles and abstracts. Grey literature and reference list searches did not identify any additional studies that met the inclusion criteria. One hundred and twelve full-text studies were assessed for eligibility, of which four studies met the eligibility criteria for inclusion in the review. All studies were randomised controlled studies with a combined total of 359 participants. All included studies were disease-specific; three studies focused on children with cancer, and one study focused on children with Attention Deficit Hyperactivity Disorder (ADHD). There was evidence that education support improved school engagement with three of four studies favouring the intervention. Three studies measured academic achievement but only two studies provided effect estimates. Based on the vote-counting method, we found contradictory results from the studies: one study showed a positive direction of effect and the other study showed a negative direction of effect. One study measured transition back to school and found a positive impact of education support favouring the intervention (SMD 0.18, 95% CI -0.46 to 0.96, no P value reported). The result came from a single study with a small sample size (n = 30), and produced a confidence interval that indicated the possibility of a very small or no effect. The overall certainty of evidence for these three outcomes was judged to be 'very low'. Two of four studies measured mental health (measured as self-esteem). Both studies reported a positive impact of education support interventions on mental health; this was the only outcome for which the overall certainty of evidence was judged to be 'low' rather than 'very low'. No studies measured or reported quality of life or adverse effects. Risk of bias (selection, performance, detection, attrition, reporting and other bias) was assessed using the Cochrane risk of bias tool for randomised trials (version 1). Overall risk of bias for all studies was assessed as 'high risk' because all studies had at least one domain at high risk of bias.

AUTHORS' CONCLUSIONS

This review has demonstrated the infancy of quality research on the effectiveness of education support interventions for children and adolescents with chronic health conditions. At best, we can say that we are uncertain whether education support interventions improve either academic achievement or school engagement. Of the secondary outcomes, we are also uncertain whether education support interventions improve transition back to school, or school re-entry. However, we suggest there is some evidence that education support may slightly improve mental health, measured as self-esteem. Given the current state of the evidence of the effectiveness of education support interventions for children and adolescents with chronic health conditions, we highlight some important implications for future research in this field to strengthen the evidence that can inform effective practice and policy.

The Effect of Filial Therapy on Depressive Symptoms of Children with Cancer and Their Mother's Depression, Anxiety, and Stress: A Randomized Controlled Trial

Background:

Childhood cancer is an overwhelming life event that can completely change the lives of the sufferers and their parents. Todays, advances of medical science have shifted the fetal nature of childhood cancer to chronic one exposing children and their family to behavioral and psychosocial problems. The aim of this study was to investigate the effect of filial therapy on children’s depressive symptoms and their mother’s stress, anxiety, and depression.

Materials and Methods:

In this randomized controlled trial, 32 mothers with their children who suffered from cancer were recruited (16 in each group). During a 10-week training sessions, filial therapy group underwent child-parent relation therapy (CPRT). Training sessions were held once a week. Control group received no training and only individual counseling sessions were held for them we needed. Both groups were assessed before and after the intervention using depression, anxiety, and stress questionnaire-21 (DASS-21), children depression inventory (CDI), and Wong-Baker faces pain rating scale (WBFPRS). Sample randomization and data analysis were conducted by using SPSS (version 20) and running independent t-test and chi-square test. P value< 0.05 was set as the significant level.

Results:

Mothers in the filial therapy group experienced significant decrease in their level of depression, anxiety, and stress in the post-test (p < 0.001). In contrast to filial therapy group, mothers in the control group did not show an improvement in their level of depression, anxiety, and stress. Moreover, the results of the current investigative showed that depression of children in the filial therapy group significantly reduced at post-test (p < 0.001). On the other hand, the mean of children’s depression in the control group remained steady.

Conclusion:

The findings of the present study revealed that using filial therapy could reduce the depression of children with cancer and their parent’s depression, anxiety, and stress. Accordingly, we suggest filial therapy programs as a routine for addressing psychosocial problems of children with cancer and their families.

Developmental Origins of Stress and Psychiatric Disorders

Over the last few decades, evidence has emerged that the pathogenesis of psychiatric disorders such as schizophrenia can involve perturbations of the hypothalamic-pituitary-adrenal (HPA) axis and other neuroendocrine systems. Variations in the manifestation of these effects could be related to differences in clinical symptoms between affected individuals and to differences in treatment response. Such effects can also arise from the complex interaction between genes and environmental factors. Here, we review the effects of maternal stress on abnormalities in HPA axis regulation and the development of psychiatric disorders such as schizophrenia. Studies in this area may prove critical for increasing our understanding of the multidimensional nature of mental disorders and could lead to the development of improved diagnostics and novel therapeutic approaches for treating individuals who suffer from these conditions.

Psychiatric outcomes associated with chronic illness in adolescence: A systematic review

Recent years have seen an increased focus on the high rates of psychiatric comorbidities in adults with chronic illness. This systematic review explored whether chronic illness in adolescents was similarly associated with poor psychiatric outcomes. The literature search identified 129 articles, only 5 of which were indicated to be at a low risk of methodological bias. Four of these articles found a strong relationship between asthma in adolescence and an increase in the prevalence of anxiety and depressive disorders, while the remaining article, which focused on diabetes mellitus, indicated similarly increased rates of psychiatric illness. Trends among the remaining studies suggested that many illnesses were not associated with poor adolescent mental health. Please note that chronic conditions with a neurological aetiology were excluded from the main review due to indications of qualitative differences in comorbidities. Findings highlight that the well-being of adolescents with chronic illness warrants a specific research focus.

Psychosocial Adjustment of Adolescent Siblings of Hematopoietic Stem Cell Transplant Patients

Hematopoietic stem cell transplantation (HSCT) is a widely practiced therapy for many life-threatening childhood disorders. The authors investigated the psychosocial effects of HSCT on siblings of pediatric HSCT patients ( n = 44; 21 donors, 23 nondonors, ages 6 to 18 years). Donor siblings reported significantly more anxiety and lower self-esteem than did nondonors. Nondonors showed significantly more school problems. Approximately one third of all siblings reported moderate to severe posttraumatic stress. The study drew on the developmental theory of Erik Erikson and the psychosocial model of posttraumatic stress. As part of the study, the authors used the Measures of Psychosocial Development (MPD), a self-report measure based on Eriksonian constructs. The MPD was used to assess the psychosocial adjustment of 12 siblings who were adolescents (≥ 13 years) at the time the study was conducted. In this article, findings are presented from the MPD as well as salient findings from the larger study.

Os efeitos do estresse na função do eixo hipotalâmico-pituitário-adrenal em indivíduos com esquizofrenia

Nas últimas décadas, têm surgido evidências sugerindo que a patogênese de desordens psiquiátricas, tais como a esquizofrenia, pode envolver perturbações no eixo hipotalâmico-pituitário-adrenal (HPA). Variações na manifestação desses efeitos poderiam estar relacionadas a diferenças em sintomas clínicos entre os indivíduos afetados, assim como a diferenças na resposta ao tratamento. Tais efeitos podem também ser originados de complexas interações entre genes e fatores ambientais. Aqui, revisamos os efeitos do estresse maternal em anormalidades na regulação do eixo HPA e desenvolvimento de desordens psiquiátricas, incluindo a esquizofrenia. Estudos nessa área podem gerar o aumento do nosso entendimento da natureza multidimensional da esquizofrenia. Posterior pesquisa nesse campo poderia, em última instância, levar ao desenvolvimento de melhores diagnósticos e novas abordagens terapêuticas para essa debilitante condição psiquiátrica.

Depression in adolescents with chronic medical illness

Chronic illness can lead to anxiety and depression in both parents and their adolescents. The identification of predictor variables would greatly assist pediatricians and parents in identifying children at risk for prolonged depression. Findings indicate that age and gender of the adolescent and duration of illness did not affect the depression score, but type of illness affected the score significantly. This article illustrates the fact that pediatricians can use the Beck Depression Inventory to identify depression and guide parents and adolescents to adequate medical care.

Effects of five parent-and-child risk factors on salivary cortisol levels and symptoms of posttraumatic stress disorder in school-age, critically ill children: pilot study

OBJECTIVE

We examined the contributions of risk factors to the psychological and neuroendocrine status of children admitted to a pediatric intensive care unit (PICU), and explored the feasibility of a full-scale study of these risk factors.

METHODS

A prospective, correlational design was used. Risk factors included parental stress, parental anxiety, child anxiety, severity of the child's illness, and invasive procedures administered to the child. Outcomes variables were pediatric posttraumatic stress disorder (PTSD) symptoms and salivary cortisol levels. Measures were taken at 3 time points over 3 months.

RESULTS

The mothers' state anxiety significantly increased over time, whereas the children's PTSD symptoms decreased. Most children with average or high anxiety demonstrated varying degrees of PTSD symptomatology, whereas children with low anxiety exhibited doubtful or mild symptoms of PTSD. As the severity of PTSD symptoms increased over time, the level of salivary cortisol decreased at two weeks and three months after hospital discharge.

CONCLUSIONS

Predicted trends in data were found and warrant further investigation, using a similar methodology in a full-scale study with an emphasis on recruiting the most seriously ill children.

Parental anxiety associated with Kawasaki disease in previously healthy children

OBJECTIVE

The objective of this study was to explore the lived experience of parents of children diagnosed with Kawasaki disease (KD) and to identify factors associated with increased levels of parental anxiety.

STUDY DESIGN

Three focus groups were conducted including 25 parents of 17 patients with KD, seven (41%) of whom had coronary artery complications. A conceptual model was developed to depict parental experiences and illustrate the key issues related to heightened anxiety.

RESULTS

Themes identified included anxiety related to the child's sudden illness and delay in obtaining a correct diagnosis because of the lack of health care providers' awareness and knowledge regarding KD. Parents were frustrated by the lack of information available in lay language and the limited scientific knowledge regarding the long-term consequences of the disease. Parents also reported positive transformations and different perspective toward challenges in life. However, the parents of children with coronary artery complications expressed persistent anxiety even years after the acute phase of the illness due to the uncertainty of the long-term prognosis.

CONCLUSIONS

There remains a critical need for richly textured research data on the perspective and experience of families of children with KD.

Practice parameter for the psychiatric assessment and management of physically ill children and adolescents

This practice parameter describes the psychiatric assessment and management of physically ill children and adolescents. It reviews the epidemiology, clinical presentation, assessment, and treatment of psychiatric symptoms in children and adolescents with physical illnesses and the environmental and social influences that can affect patient outcome.

Sexuality issues and gynecologic care of adolescents with developmental disabilities

All human beings are sexual from birth to death and all children and adolescents with or without disability or chronic illness must incorporate appropriate sexuality concepts into their processes of development from childhood to adolescence. This article considers sexuality issues and reproductive care of adolescents with developmental disabilities. Potential consequences of disability on sexuality are reviewed, including sexual abuse and sexual dysfunction. Comprehensive sexuality education is vital for normal growth and development of all youth including those with developmental disabilities.

Developing the Children's Critical Illness Impact Scale: capturing stories from children, parents, and staff

OBJECTIVE

With the evolution of pediatric critical care medicine has come an awareness of the ethical imperative of healthcare professionals to attend to the psychological sequelae of technologically intensive care. Recent attempts to measure psychological outcomes in these children have been limited. The purpose of this study was to develop a measure of posthospitalization distress, the Children's Critical Illness Impact Scale (CCIIS), for children aged 6-12 yrs following pediatric intensive care unit hospitalization.

DESIGN

A measurement development study consisting of two phases: 1) item generation and scale formatting; and 2) item reduction and scale revisions. Items were generated following thematic analysis of qualitative data from focus groups and individual interviews with children, parents, and healthcare professionals. Children reviewed items for interpretability and importance and assessed scaling technique and item presentation; healthcare professionals further evaluated item relevance.

SETTING

The pediatric intensive care units of three quaternary care, Canadian pediatric teaching hospitals.

PATIENTS

Phase 1 included 18 children, 22 parents, and 12 healthcare professionals (n = 52). Phase 2 included eight children and four healthcare professionals (n = 12).

MEASUREMENTS AND MAIN RESULTS

Five key domains were identified in the thematic analyses: worries, fears, friends and family, sense of self, and behaviors. Thirty-six items were initially generated, and subsequent item reduction resulted in 23 items that were retained on the final scale. Items were generally rated extremely relevant and were judged to capture the content area (content validity index = 0.87). The CCIIS was easily understood, and the scaling format worked well. Older children preferred written items, while younger children will require a modified, pictorial version.

CONCLUSIONS

The CCIIS is a new self-report measure with demonstrated content validity and specific relevance for young school-aged children following pediatric intensive care unit hospitalization. Valid, accessible, and developmentally appropriate measures are essential to identify high-risk children and, ultimately, promote healthy growth and development.

Psychological problems and quality of life in children with thalassemia

OBJECTIVE

The study is aimed to assess psychological problems and quality of life (QOL) in children with thalassemia.

METHODS

Thirty-nine children (8-16 yr) with transfusion dependent thalassemia attending day care services for blood transfusion were assessed for psychological problems using the Childhood Psychopathology Measurement Schedule and QOL was assessed using the EQ-5D.

RESULTS

Forty-four percent of the children had psychological problems and 74% had a poor QOL. Anxiety-related symptoms (67%), emotional problems, particularly depression (62%) and conduct problems (49%) were the main findings. The children were most likely to report impaired QOL due to severe difficulties in pain/discomfort (64%) dimension, followed by depression and mobility problems of equal severity (33%). The side effects of chelation were an independent predictor of psychological problems and impaired QOL. Also psychological problems were a significant predictor of impaired QOL.

CONCLUSION

The recognition and management of the psychological problems that accompany chronic physical illnesses including thalassemia would optimize treatment outcomes and QOL.

Family interactions of liver transplanted children: are they normal?

Several psychosocial and behavioral problems have been reported in liver transplanted children. Most publications have focused on them, without considering their family environment. The aim of this study was to evaluate the interaction between liver transplanted children and their families, compared with a healthy control group. We selected liver transplanted children, between 8 and 12 years of age, with at least 6 months follow-up posttransplantation and in good clinical condition. Family structure also included 1 to 3 other children. Evaluable patients must have been living with their parents throughout the whole posttransplantation period. They were compared with a similar group of children without any chronic disease. A written informed consent was signed by both parents. All families were evaluated using a standard test consisting of different situations. The information was evaluated by 3 independent experts. Factors evaluated were limits (rules and limits of behavior), alliance-opposition (interaction between members to act), and hierarchy. Scoring was given to all observed acts. Statistical analysis was performed using chi-square tests with P < .05 considered significant. No statistical differences were found between groups in limits, alliance, and hierarchy. Our results showed that there were no differences in family structure and behavior between families of liver-transplanted and healthy children belonging to a similar socioeconomic level.

Quality of life issues in caregivers of youngsters with thalassemia

OBJECTIVE

To assess the contribution of psychiatric problems, concerns regarding the illness to Quality of Life (QOL) in caregivers.

METHODS

Forty four caregivers were screened for psychiatric problems using the General Health Questionnaire 12 item version (GHQ-12) and their concerns and QOL were assessed using the Concerns Checklist and the EQ5D respectively. Clinical psychiatric interview was conducted for those qualifying for GHQ caseness and a psychiatric diagnosis was ascribed. These were correlated with the Childhood Psychopathology Measurement Schedule/ GHQ- 12 scores (as appropriate) and the EQ5D score of the youngster.

RESULTS

Fifty seven percent of the caregivers had psychiatric problems, with depressive disorders in 19/44 (45%) QOL was affected in 50% (Pain/ discomfort (n =19, 45%), Mobility (n = 7, 17%), Depression and Usual activities dimensions (n= 6, 14% each). The greatest concerns were regarding the future (91%), illness (80%) and finances (73%).

CONCLUSION

Caregiver support through psychological interventions or medication would alleviate psychiatric problems and concerns and contribute towards a better QOL.

Hematopoietic stem cell donation in children: a review of the sibling donor experience

Hematopoietic Stem Cell Transplant (HSCT) represents the second most frequent major organ transplant in the United States. Compared with other family members, siblings are more likely to be immunologically matched with the recipient and therefore are often the most suitable donors. Due to a dearth of information on the positive and adverse effects of HSCT on pediatric sibling donors, we sought to examine available data. Eight published reports assessing the pediatric sibling donor experience were identified in the literature. Studies were predominately small (n < 44) and cross-sectional. Results suggest a range of psychological distress responses with higher distress in pediatric donor than non-donor siblings. Recommendations include future longitudinal research on sibling donor psychosocial adjustment, identification of sibling donors at high risk for maladaptive responses, and development of educational and psychosocial interventions for this overlooked pediatric population.

Posttraumatic stress disorder in medically ill patients: what is known, what needs to be determined, and why is it important?

Can a medical illness or its treatment qualify as an emotionally traumatic event and can it cause posttraumatic stress disorder symptoms? If so, can the view of a medical illness as a traumatic experience enhance our ability to understand patients' adjustment to illness and their emotional reactions to it? Is it important to identify posttraumatic symptoms and try to address them in medically ill patients? These questions form the backbone for this review. Because many questions remain unanswered (or the answers are not definitive yet), we concisely summarize the issues and present our own view of the most pressing questions for further research.

Development and Validation of the Parent Experience of Child Illness

OBJECTIVE

To develop a measure of parent adjustment related to caring for a child with a chronic illness and to evaluate the reliability and validity of the measure with a group of parents of children with brain tumors.

METHODS

One-hundred forty-nine parents of patients (age <1-17 years) diagnosed with a brain tumor were assessed using the 25-item self-report Parent Experience of Child Illness (PECI). Internal consistency, construct validity, and factor structure were assessed.

RESULTS

Exploratory factor analysis yielded four theoretically coherent factors including: Guilt and Worry, Emotional Resources, Unresolved Sorrow and Anger, and Long-term Uncertainty. Internal reliability for the PECI scales ranged from .72 to .89, suggesting acceptable reliability. As evidence of construct validity, the PECI scales show significant, positive correlations with scales from established measures of parent adjustment.

CONCLUSION

The PECI augments the current literature by providing a brief measure of parents' subjective distress and perceived Emotional Resources, domains that are critical but understudied in children with chronic illness and their caregivers.

Psychiatric morbidity and quality of life in children with malignancies and their parents

Recent improvements in prognosis necessitate considering the emotional responses of children with malignant diseases and of their parents. This prospective study assessed 20 children and adolescents and their 36 parents within 2 weeks of diagnosis and after 1 and 6 months. Fifty-three percent exhibited moderate to severe posttraumatic symptoms right after diagnosis that decreased significantly after 1 month. Children with high-risk disease reported the most severe symptoms. Unexpectedly, children with low-risk disease exhibited more severe symptoms than those with moderate risk. Depressive symptoms decreased significantly during the period, but anxiety symptoms did not. Moreover, quality of life did not change. Twenty percent of parents exhibited posttraumatic symptoms on initial evaluation. Mothers' symptoms did not change, but fathers' symptoms decreased with those of their children. Several procedures and experiences were identified as causes of traumatic stress responses.

Stress levels experienced by the parents of enterally fed children

BACKGROUND

The stress levels of parents of children with chronic illness/disability who were also involved in an enteral feeding programme were examined and compared to the stress levels of parents of healthy children and parents of children with other chronic illnesses reported in previous research.

METHODS

Sixty-four parents who had a child with an enteral feeding tube completed the Parenting Stress Index (PSI).

RESULTS

Based on criteria developed by Abidin (1995), 42.18% (n = 29) of these parents displayed high stress levels. T-tests revealed that Total Stress scores on the PSI of the parents of children involved in the enteral feeding programme were significantly higher than those reported in the sample of parents used to norm the PSI (P < 0.001), and comparison samples of parents of children with growth deficiencies (P < 0.001) and parents of children with insulin-dependent diabetes mellitus (P < 0.01). Compared to a sample of parents of children with Rett syndrome, the parents of children involved in the enteral feeding programme reported similar levels of stress on the Parent Domain of the PSI and significantly less stress on the Child Domain (P < 0.001).

CONCLUSIONS

Factors associated with the stress reported by parents of children with an enteral feeding tube were severity of their child's illness/disability, the constant caretaking demands placed on the parent, and the level of support provided by the parents' social network.

Psychosocial adjustment and quality of life after renal transplantation in early childhood

Psychosocial adjustment and quality of life has been reported good in children after a successful renal transplantation (Tx). There are, however, few reports of using standardized methods in evaluating these issues, particularly in small children. We investigated the psychosocial adjustment in 32 children at school age (mean 9.6 +/- 1.6), who had received a renal Tx under the age of 5 yr, using the Achenbach Child Behavior Checklist with data collected from both parents (CBCL) and teachers (CBCL-TRF). Health-related quality of life (HRQOL) was assessed by interviewing the children using a 17-dimensional (17D) health-related measure and compared to HRQOL of 244 normal school children. The effect of additional diseases and comorbidity on psychosocial adjustment and HRQOL was assessed. The total scores on the CBCL did not differ from normative samples of healthy children. However, somatic complaints and social problems were reported more frequently in boys, and attention problems in both boys and girls. Patients with pathological scores had significantly more comorbidity (p = 0.03) and were more often attending a special school (p = 0.007) than patients with normal scores. The global 17D HRQOL index was significantly lower than measured in healthy controls (94 +/- 5 for controls and 85 +/- 7 for patients, p < 0.0001). It is of crucial importance to further minimize the risk factors leading to comorbidity in children after Tx. HRQOL assessment by the children themselves can be used to direct interventions and support the children's psychosocial adjustment.

Psychosocial adaptation after solid organ transplantation in children

The possibility of extending life with advanced medical procedures such as organ transplantation in childhood has made it possible to focus on patients' well-being in a wider perspective. They still experience a high prevalence of medical and physical disabilities, which definitively have an impact on a child's psychosocial adjustment after transplantation. Many disabilities originate before transplantation, and much effort should be taken to diminish possible complications and ameliorate growth and neurodevelopment, which have an impact for later adjustment regardless of a successful transplantation. Well-being and QOL are not necessarily always correlated to the degree of physical disability. Different social, financial, and demographic factors also have an impact, as do children's and families' ability to cope with a chronic disorder. Nonadherence and noncompliance are a great problem, particularly in adolescents. They are the result and a possible cause of inferior psychosocial adjustment. Continuous multidisciplinary support, follow-up, and education are needed to cope with this problem. Validated and reliable health status measures in pediatric transplant recipients are scarce in the literature, and few assessments can be completed by the children themselves. A continuing effort must be made to improve psychosocial adjustment and QOL after transplantation to achieve the ultimate goal in medicine: the overall well-being of our patients.

Posttraumatic stress responses in children with life-threatening illnesses

Posttraumatic stress symptoms have been reported in response to various serious medical illnesses in adults and children. Not surprisingly, posttraumatic stress is probably more common in response to acute, life-threatening, events that are related to the illness. Emerging data suggest that children often experience life-saving medical procedures as traumatic, which puts caretakers and medical personnel in the role of perpetrators for the children. Trauma symptoms are also reported as common and severe in caregivers. Both of these issues have been previously poorly understood and should be addressed in assessment and treatment. As with other traumatic events, developmental considerations, the nature and severity of the event itself, social supports, and premorbid exposure to negative life events are also important issues to consider in developing appropriate interventions. The importance of developing prevention and treatment for PTSD in medically ill children and adults includes increased morbidity and mortality (e.g., nonadherence to medications) and psychiatric sequelae and decreased quality of life. Obstacles to systematic study of a psychiatric intervention for this group include difficulties assessing multidrug regimens and cognitive treatment effects in this group. The relative stability of social supports and the potential use of preventive measures make this an attractive population for intervention. Clinicians and researchers are encouraged to work together to develop and use uniform screening and assessment methods that will help to identify cases and facilitate the multicenter trials that are vital to increasing knowledge in this patient population.

Psychosocial issues and coping strategies in families affected by urea cycle disorders

A survey was sent to the American members of the National Urea Cycle Disorders Foundation to ascertain the types and extent of stress imposed on families who have a child with a urea cycle defect. Forty percent of the surveys were returned. The greatest sources of stress were financial, fear of death, and the restrictions imposed by the diet. Other than removal of the economic stress and uncertainty, the results did not suggest that any specific support systems required augmentation. Instructions to mitigate frustrations occurring in emergency situations would, however, be a great help to families.

Psychosocial aspects of chronic illness in adolescence

Success in the survival of children with significant medical conditions has resulted in a dramatic increase in the prevalence of adolescents with chronic illness. Unfortunately, the traditional biomedical approach does not prepare practitioners for the complexities of managing chronic illness, because numerous psychosocial factors are involved. This article will address the need for integrating psychosocial issues into the assessment and treatment of the chronically ill adolescent. Assessment of the teen should incorporate an understanding of the developmental stages of adolescence, a review of how these developmental tasks are being accomplished, a discernment of individual characteristics, and knowledge of the family and community to which they belong. Management should take into account the phases of illness (acute, chronic or terminal) and encourage empowerment of the adolescent and family in decision making. A team approach that is community-based, comprehensive, and culturally appropriate is ideal.

Depression in pediatric chronic illness. A diathesis-stress model

Depression in pediatric chronic illness has been receiving increasing attention in recent years. Studies to date have typically focused on characteristics of illness as the major determinants of the development of depression, but characteristics of the child have received less attention. This review suggests that a diathesis-stress model can be a fruitful heuristic that would incorporate illness characteristics and attributes of the child and environmental effects in an overall framework to guide future research and treatment.

Management of chronic medical conditions in children and adolescents

The care of children and adolescents with chronic medical conditions is an area of great interest for primary care physicians. With longer lives and more "mainstreaming" of care, the primary care physician often finds an increased role in the management of children and adolescents with chronic conditions such as mental retardation, Down syndrome, and diabetes mellitus. This article discusses familiarity with the most common chronic conditions and common pitfalls of management.